All Relationships Are to the Child

GeorgiaDepartment of Human Resources

BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD

Responsible Party / Birth Name of Child

Telephone Number

/ Date / Date of Birth of Child / Time of Birth / Sex
ResidentCounty / PlacementCounty / Race/Ethnic

ALL RELATIONSHIPS ARE TO THE CHILD (CHILD’S NAME / )
CHILD’S / Mother / Grandmother / Grandfather / Father / Grandmother / Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

CHILD’S MATERNAL AUNTS & UNCLES /

CHILD’S MATERNAL AUNTS & UNCLES

Date of Birth:
Sex:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:
REASON BIRTH PARENTS PLACED THIS CHILD FOR ADOPTION:
Form 413 (rev.7-98) /

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Page 1 of 7

ALL RELATIONSHIPS ARE TO THE CHILD

SIBLINGS OF CHILD

MATERNAL

DATE OF BIRTH:
FULL OR HALF SIBLING:
SEX:
HAIR COLOR:
EYE COLOR:
COMPLEXION:
GENERAL BUILD:
GENERAL HEALTH:
SCHOOL GRADE AND ACHIEVEMENT:
SPECIAL CHARACTERISTICS:

PATERNAL

DATE OF BIRTH:
FULL OR HALF SIBLING:
SEX:
HAIR COLOR:
EYE COLOR:
COMPLEXION:
GENERAL BUILD:
GENERAL HEALTH:
SCHOOL GRADE AND ACHIEVEMENT:
SPECIAL CHARACTERISTICS:
Form 413 (rev.7-98) /

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Page 2 of 7

ALL RELATIONSHIPS ARE TO THE CHILD

FAMILY OF CHILD’S MOTHER

Maternal / Paternal
CHILD’S /

Great Grandmother

/ Great Grandfather /

Great Grandmother

/ Great Grandfather
DATE OF BIRTH:
RACE/ETHNIC:
NATIONAL DESCENT:
HAIR COLOR:
EYE COLOR:
COMPLEXION:
GENERAL BUILD:
OCCUPATION:
EDUCATION:
SPECIAL CHARACTERISTICS:
IF DECEASED,
AGE & CAUSE:
Maternal Great Aunts and Uncles / Paternal Great Aunts and Uncles
DATE OF BIRTH: / /
SEX:
RACE/ETHNIC:
NATIONAL DESCENT:
HAIR COLOR:
EYE COLOR:
COMPLEXION:
GENERAL BUILD:
OCCUPATION:
EDUCATION:
SPECIAL CHARACTERISTICS:
IF DECEASED,
AGE & CAUSE:
Form 413 (rev.7-98) /

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Page 3 of 7

ALL RELATIONSHIPS ARE TO THE CHILD

FAMILY OF CHILD’S FATHER

Maternal / Paternal
CHILD’S /

Great Grandmother

/ Great Grandfather /

Great Grandmother

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Page 4 of 7

ALL RELATIONSHIPS ARE TO THE CHILD

FAMILY MEDICAL INFORMATION

MATERNAL

Check YES or NO to each of the following diseases or conditions, if the answer is YES give family member, and brief description of disease/condition, its effect, age of onset, age if cause of death, in the space below.

1. Allergies / Yes / No / Yes / No / Yes / No
aa) drugs / 7 Congenial Birth Abnormalities / b) premature births
b) foods / 8. Cleft Lip / c) still births
c) asthma / 9. Cleft Palate / d) incompetent cervix
d) hay fever / 10. Cystic Fibrosis / e) ectopic pregnancies
e) other / 11. Diabetes / f) eclamptogenic toxemia
2. Alcoholism/ / 12. Dwarfism / g) spontaneous abortion
Drug Addiction / 13. Epilepsy / h) other
3. Blood Diseases / 14. Hearing Disorders / 29. Respiratory Diseases
a) hemophilia / 15. Huntington Disease / a) emphysema
b) Rh disease / 16. Hyperactivity (ADHD) / b) bacterial pneumonia
c) sickle cell disease /trait / 17. Immune System Disease / c) tuberculosis
d) other / a) HIV Positive / d) other
4. Bone Diseases / b) AIDS / 30. Skin Disorders
a) arthritis / 18. Learning Disability (specify) / a) psoriasis
b) curvature of spine / b) other
c) other structural / 31. Speech Disorders
malformation / 19. Liver Disease / a) stuttering
d) other / 20. Mental Illness / b) tongue tie
5. Cancer / a) bi-polar / c) sound omissions
a) breast / b) schizophrenia / d) sound distortions
b) bowel / c) other / e) delayed speech
c) colon / 21. Mental Retardation / f) other
d) ovarian / a) Downs Syndrome / 32. Sudden Infant Death
e) skin / b) PKU / 33. Systemic Lupus
f) stomach / c) Lesch-Nyham syndrome / Erythematosis
g) lungs / d) Hunters / 34. Thyroid Disorders
h) leukemia / e) tubercous scierosis / 35. Tay-Sachs Disease
i) other / f) other / 36. Tourette Syndrome
6. Cardiovascular / 22. Migraine Headache / 37. Visual Disorders
Disease / 23. Multiple Births / a) cataracts
a) Atheroscierosis / 24. Multiple Sclerosis / b) dyslexia
b) congenial heart disease / 25. Muscular Dystrophy / c) glaucoma
c) heart attack / 26. Myasthenia Gravis / d) retinnitis pigmentosa
d) hyperlipdemia / 27. Obesity / e) strabismus
e) stroke / 28. Pregnancy Complications / f) other
f) high blood pressure / a) Drug/alcohol use / 38. Any other diseases which have
Occurred repeatedly in family. (specify)
g) other / during pregnancy
Biological Mother’s age at onset of menses ______
Code number and letter when describing disease/condition. Attach additional page if needed)
Form 413 (rev.7-98) /

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Page 5 of 7

ALL RELATIONSHIPS ARE TO THE CHILD

FAMILY MEDICAL INFORMATION

PATERNAL

1. Allergies / Yes / No / Yes / No / Yes / No
aa) drugs / 7 Congenial Birth Abnormalities / b) premature births
b) foods / 8. Cleft Lip / c) still births
c) asthma / 9. Cleft Palate / d) incompetent cervix
d) hay fever / 10. Cystic Fibrosis / e) ectopic pregnancies
e) other / 11. Diabetes / f) eclamptogenic toxemia
2. Alcoholism/ / 12. Dwarfism / g) spontaneous abortion
Drug Addiction / 13. Epilepsy / h) other
3. Blood Diseases / 14. Hearing Disorders / 29. Respiratory Diseases
a) hemophilia / 15. Huntington Disease / a) emphysema
b) Rh disease / 16. Hyperactivity (ADHD) / b) bacterial pneumonia
c) sickle cell disease /trait disease/trait / 17. Immune System Disease / c) tuberculosis
d) other / a) HIV Positive / d) other
4. Bone Diseases / b) AIDS / 30. Skin Disorders
a) arthritis / 18. Learning Disability (specify) / a) psoriasis
b) curvature of spine / b) other
c) other structural / 31. Speech Disorders
malformation / 19. Liver Disease / a) stuttering
d) other / 20. Mental Illness / b) tongue tie
5. Cancer / a) bi-polar / c) sound omissions
a) breast / b) schizophrenia / d) sound distortions
b) bowel / c) other / e) delayed speech
c) colon / 21. Mental Retardation / f) other
d) ovarian / a) Downs Syndrome / 32. Sudden Infant Death
e) skin / b) PKU / 33. Systemic Lupus
f) stomach / c) Lesch-Nyham syndrome / Erythematosis
g) lungs / d) Hunters / 34. Thyroid Disorders
h) leukemia / e) tubercous scierosis / 35. Tay-Sachs Disease
i) other / f) other / 36. Tourette Syndrome
6. Cardiovascular / 22. Migraine Headache / 37. Visual Disorders
Disease / 23. Multiple Births / a) cataracts
a) Atheroscierosis / 24. Multiple Sclerosis / b) dyslexia
b) congenial heart disease / 25. Muscular Dystrophy / c) glaucoma
c) heart attack / 26. Myasthenia Gravis / d) retinnitis pigmentosa
d) hyperlipdemia / 27. Obesity / e) strabismus
e) stroke / 28. Pregnancy Complications / f) other
f) high blood pressure / a) Drug/alcohol use / 38. Any other diseases which have
Occurred repeatedly in family. (specify)
g) other / during pregnancy
Biological Mother’s age at onset of menses ______
Code number and letter when describing disease/condition. Attach additional page if needed)
Form 413 (rev.7-98) /

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Page 6 of 7

ALL RELATIONSHIPS ARE TO THE CHILD

NAMES AND ADDRESSES

CHILD:
NAME / DATE OF BIRTH / ADDRESS
MATERNAL
NAME / DATE OF BIRTH / ADDRESS
CHILD’S MOTHER:
GRANDMOTHER:
GRANDFATHER:
AUNTS & UNCLES:
SIBLINGS:
PATERNAL
NAME / DATE OF BIRTH / ADDRESS
CHILD’S FATHER:
GRANDMOTHER:
GRANDFATHER:
AUNTS & UNCLES:
SIBLINGS

Is mother aware of the provisions of 19-8-23(f) (Reunion Registry)YESNO

Is father aware of the provisions of 19-8-23(f) (Reunion Registry)YESNO

Form 413 (rev.7-98) /

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Page 7 of 7

GEORGIA LAW ON ADOPTION RECORDS AND (KEEP THESE PAGES)

RIGHTS TO INFORMATION BETWEEN ADOPTEES AND BIRTHPARENTS

O.C.G.A. §19823. Where records of adoption kept; examination by parties and attorneys; use of information by agency and department. ["department" herein means the Georgia Department of Human Resources]

(a) The original petition, all amendments and exhibits thereto, all motions, documents, affidavits, records, and testimony filed in connection therewith, and all decrees or orders of any kind whatsoever, except the original investigation report and background information referred to in Code Section 19820, shall be recorded in a book kept for that purpose and properly indexed; and the book shall be part of the records of the court in each county which has jurisdiction over matters of adoption in that county. All of the records, including the docket book, of the court granting the adoption, of the department, and of the childplacing agency that relate in any manner to the adoption shall be kept sealed and locked. The records may be examined by the parties at interest in the adoption and their attorneys when, after written petition has been presented to the court having jurisdiction and after the department and the appropriate childplacing agency have received at least 30 days' prior written notice of the filing of such petition, the matter has come on before the court in chambers and, good cause having been shown to the court, the court has entered an order permitting such examination. Notwithstanding the foregoing, if the adoptee who is the subject of the records sought to be examined is less than 18 years of age at the time the petition is filed and the petitioner is someone other than one of the adoptive parents of the adoptee, then the department shall provide written notice of such proceedings to the adoptive parents by certified mail or statutory overnight delivery, return receipt requested, at the last address the department has for such adoptive parents and the court shall continue any hearing on the petition until not less than 60 days after the date the notice was sent. Each such adoptive parent shall have the right to appear in person or through counsel and show cause why such records should not be examined. Adoptive parents may provide the department with their current address for purposes of receiving notice under this subsection by mailing that address to:

Office of Adoptions, Department of Human Resources, Atlanta, Georgia

(b) The department or the childplacing agency may, in its sole discretion, make use of any information contained in the records of the respective department or agency relating to the adoptive parents in connection with a subsequent adoption matter involving the same adoptive parents or to provide notice when required by subsection (a) of this Code section.

(c) The department or the childplacing agency may, in its sole discretion, make use of any information contained in its records on a child when an adoption disrupts after finalization and when such records are required for the permanent placement of such child, or when the information is required by federal law.

(d)(1) Upon the request of a party at interest in the adoption or of a provider of medical services to such a party when certain information is necessary because of a medical emergency or for medical diagnosis or treatment, the department or childplacing agency may, in its sole discretion, access its own records on finalized adoptions for the purpose of adding subsequently obtained medical information or releasing nonidentifying medical information contained in its records on such adopted persons.

(2) Upon receipt by the Office of Adoptions of the department or by a child-placing agency of documented medical information relevant to an adoptee, the office or child-placing agency shall use reasonable efforts to contact the adoptive parents of the adoptee or the adoptee if he or she is 18 years of age or older and provide such documented medical information to the adoptive parents or the adoptee. The office or child-placing agency shall be entitled to reimbursement of reasonable costs for postage and photocopying incurred in the delivery of such documented medical information to the adoptive parents or adoptee.

(e) Records relating in any manner to adoption shall not be open to the general public for inspection.

(f)(1)Notwithstanding Code Section 1981, for purposes of this subsection, the term:

(A) 'Biological parent' means the biological mother or biological father who surrendered that person´s rights or had such rights terminated by court order giving rise to the adoption of the child.

(B) 'Commissioner' means the commissioner of human resources or that person´s designee.

(C) 'Department' means the Department of Human Resources or, when the Department of Human Resources so designates, the county department of family and children services which placed for adoption the person seeking, or on whose behalf is sought, information under this subsection.

(D) 'Placement agency' means the childplacing agency, as defined in paragraph (3) of Code Section 1981, which placed for adoption the person seeking or on whose behalf is sought information under this subsection.

(f)(2)The department or a placement agency, upon the written request of an adopted person who has reached 18 years of age or upon the written request of an adoptive parent on behalf of that parent´s adopted child, shall release to such adopted person or to the adoptive parent on the child´s behalf nonidentifying information regarding such adopted person´s biological parents and information regarding such adopted person´s birth. Such information may include the date and place of birth of the adopted person and the genetic, social, and health history of the biological parents. No information released pursuant to this paragraph shall include the name or address of either biological parent or the name or address of any relative by birth or marriage of either biological parent.

(f)(3)(A) The department or a placement agency upon written request of an adopted person who has reached 21 years of age shall release to such adopted person the name of such person´s biological parent if [3 conditions]:

(i) The biological parent whose name is to be released has submitted unrevoked written permission to the department or the placement agency for the release of that parent´s name to the adopted person;

(ii) The identity of the biological parent submitting permission for the release of that parent´s name has been verified by the department or the placement agency; AND

(iii) The department or the placement agency has records pertaining to the finalized adoption and to the identity of the biological parent whose name is to be released.

(B) If the adopted person is deceased and leaves a child, such child, upon reaching 21 years of age, may seek the name and other identifying information concerning his or her grandparents in the same manner as the deceased adopted person and subject to the same procedures contained in this Code section.

(f)(4)(A) If a biological parent has not filed written unrevoked permission for the release of that parent´s name to the adopted child, the department or the placement agency, within six months of receipt of the written request of the adopted person who has reached 21 years of age, shall make diligent effort to notify each biological parent identified in the original adoption proceedings or in other records of the department or the placement agency relative to the adopted person. For purposes of this subparagraph, 'notify' means a personal and confidential contact with each biological parent of the adopted person. The contact shall be by an employee or agent of the placement agency which processed the pertinent adoption or by other agents or employees of the department. The contact shall be evidenced by the person who notified each parent certifying to the department that each parent was given the following information:

(i) The nature of the information requested by the adopted person;

(ii) The date of the request of the adopted person;

(iii) The right of each biological parent to file an affidavit with the placement agency or the department stating that such parent´s identity should not be disclosed;

(iv) The right of each biological parent to file a consent to disclosure with the placement agency or the department; and

(v) The effect of a failure of each biological parent to file either a consent to disclosure or an affidavit stating that the information in the sealed adoption file should not be disclosed.

(B) If a biological parent files an unrevoked consent to the disclosure of that parent´s identity, such parent´s name shall be released to the adopted person who has requested such information as authorized by this paragraph.

(C) If, within 60 days of being notified by the department or the placement agency pursuant to subparagraph (A) of this paragraph, a biological parent has filed with the department or placement agency an affidavit objecting to such release, information regarding that biological parent shall not be released.

(D)(i) If six months after receipt of the adopted person´s written request the placement agency or the department has either been unable to notify a biological parent identified in the original adoption record or has been able to notify a biological parent identified in the original adoption record but has not obtained a consent to disclosure from the notified biological parent, then the identity of a biological parent may only be disclosed as provided in division (ii) or (iii) of this subparagraph.

(ii) The adopted person who has reached 21 years of age may petition the SuperiorCourtofFultonCounty to seek the release of the identity of each of that person´s biological parents from the department or placement agency. The court shall grant the petition if the court finds that the department or placement agency has made diligent efforts to locate each biological parent pursuant to this subparagraph either without success or upon locating a biological parent has not obtained a consent to disclosure from the notified biological parent and that failure to release the identity of each biological parent would have an adverse impact upon the physical, mental, or emotional health of the adopted person.

(iii) If it is verified that a biological parent of the adopted person is deceased, the department or placement agency shall be authorized to disclose the name and place of burial of the deceased biological parent, if known, to the adopted person seeking such information without the necessity of obtaining a court order.

(f)(5)(A) Upon written request of an adopted person who has reached 21 years of age or a person who has reached 21 years of age and who is the sibling of an adopted person, the department or a placement agency shall attempt to identify and notify the siblings of the requesting party, if such siblings are at least 18 years of age. Upon locating the requesting party´s sibling, the department or the placement agency shall notify the sibling of the inquiry. Upon the written consent of a sibling so notified, the department or the placement agency shall forward the requesting party´s name and address to the sibling and, upon further written consent of the sibling, shall divulge to the requesting party the present name and address of the sibling. If a sibling cannot be identified or located, the department or placement agency shall notify the requesting party of such circumstances but shall not disclose any names or other information which would tend to identify the sibling. If a sibling is deceased, the department or placement agency shall be authorized to disclose the name and place of burial of the deceased sibling, if known, to the requesting party without the necessity of obtaining a court order.